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13УДК: 616.12-005.4-06:616.89-008.45 CLASSIFICATION AND PROPERTIES OF MESH EXPLANTS FOR HERNIOPLASTY OF HERNIAL DEFECTS OF THE ANTERIOR ABDOMINAL WALL (REVIEW)
KHAMDAMOVILHOMJON BAKHTIYOROVICH Independent applicant of the department of hospital and faculty surgery, urology, Bukhara State Medical Institute named after Abu Ali Ibn Sino, city of Bukhara, Republic of Uzbekistan.
ORCID ID 0000-0001-5104-8571 KHAMDAMOV ALISHERJON BAKHTIYOROVICH Master's student of the department of hospital and faculty surgery, urology, Bukhara State Medical Institute named after Abu Ali Ibn Sino, city of Bukhara, Republic of Uzbekistan. ORCID ID 000-0001-6614-4806
ABSTRACT
The most modern and refined classifications of mesh explants are presented. A systematic approach to the problem based on a clear stratification of patients in relation to the risk of complications is reflected. Differences and controversial points of view regarding terminology, the latest concepts and definitions in abdominal wall hernia surgery are presented.
Key words: hernia, hernioplasty, mesh, complications of prosthetic plastic surgery.
КЛАССИФИКАЦИЯ И СВОЙСТВА СЕТЧАТЫХ ЭКСПЛАНТАТОВ ДЛЯ ГЕРНИОПЛАСТИКИ ГРЫЖЕВЫХ ДЕФЕКТОВ ПЕРЕДНЕЙ
БРЮШНОЙ СТЕНКИ (ОБЗОР)
ХАМДАМОВ ИЛХОМ БАХТИЁРОВИЧ
Самостоятельный соискатель кафедры госпитальный и факультетный хирургии, урологии Бухарского Государственного медицинского института имени Абу Али Ибн Сино, город Бухара Республика Узбекистан. ORCID Ю 0000-0001-5104-8571
ХАМДАМОВ АЛИШЕР БАХТИЁРОВИЧ Магистрант кафедры госпитальный и факультетный хирургии, урологии Бухарского Государственного медицинского института имени Абу Али Ибн Сино, город Бухара Республика
Узбекистан. О^С1Ю Ю 0000-0001-6614-4806 АННОТАЦИЯ
Представлены наиболее современные и уточненные классификации сетчатых эксплантатов. Отражен системный подход к проблеме на основе четкой стратификации пациентов в отношении риска осложнений. Приведены отличия и спорные точки зрения относительно терминологии, новейших понятий и определений в хирургии грыж брюшной стенки.
Ключевые слова: грыжа, герниопластика, сетка, осложнения протезирующей пластики.
КОРИН ОЛД ДЕВОРИ НУКСОНЛАРИНИНГ ГЕРНИОПЛАСТИКАСИ УЧУН ТУР ЭКСПЛАНТЛАРИНИНГ ТАСНИФИ ВА ХУСУСИЯТЛАРИ
ХАМДАМОВ ИЛХОМ БАХТИЁРОВИЧ
Факультет ва госпитал хирургия, урология кафедраси мустацил изланувчиси, Бухоро давлат тиббиёт институти, Бухоро, Узбекистон ORCID Ю 0000-0003-4037-4333
ХАМДАМОВ АЛИШЕР БАХТИЁРОВИЧ
Факультет ва госпитал хирургия, урология кафебраси магистранти, Бухоро бавлат тиббиёт институти, Бухоро,
Узбекистон ORCID ID 0000-0001-6614-4806 АННОТАЦИЯ
Ушбу мацолаба тур эксплантларининг энг замонавий ва нозик таснифлари келтирилган. Беморларнинг асоратлар хавфига нисбатан аниц табацаланишига асосланган муаммога тизимли ёнбашув уз аксини топган. Термин билан боглиц фарцлар ва мунозара, цорин бевори жарроцлик янги тушунчалари ва таъриф келтирилган.
Калит сузлар: чурра, герниопластика, тур, протез пластик жарроцликнинг асоратлари.
The prevalence of hernias among the world's population is approximately 5-6% - [1, 3, 5, 12]. This makes hernioplasty one of the most frequently performed operations worldwide. Among all surgical operations, hernia section ranks third after appendectomy and cholecystectomy [4]. Inguinal and femoral hernias account for approximately 75%, ventral hernias - 15-20% - [2, 3, 5, 12]. In the United States, about one million hernia surgeries are performed per year. An analysis conducted in the UK in 1996 showed that among the local population, 27% of men and 3% of women will be operated on for inguinal hernia during their lifetime - [1]. The analysis of publications revealed the frequency of postoperative ventral hernias with various accesses to the abdominal cavity: after median laparotomy - 10.5%, after transverse access - 7.5%, after paramedial access - 2.5%. In cases of infection after laparotomy, the frequency of postoperative ventral hernia formation is doubled - [2]. Ventral hernias not only bring aesthetic discomfort, but also reduce the quality of life, limiting the functional capabilities of patients. The wide
prevalence of hernias among people of working age determines the high social and economic significance of this problem. Relapses in the treatment of hernias with local tissues are very high and 13 reach 50% in postoperative ventral hernias - [2, 6, 12]. The use of synthetic prostheses significantly reduces the frequency of relapses, according to various authors, to 11-19.5% - [1, 3, 4, 5]. However, the frequency of other complications of hernioplasty remains high. Since the mid-40s of the twentieth century, synthetic materials have been widely used. Since then, thanks to the development of industry, the accumulated experience of surgeons, conducted clinical and pathomorphological studies, there has been a significant evolution of synthetic prosthetic materials from polyethylene to modern polypropylene, membrane, composite and biological prostheses - [3]. The introduction of mesh prostheses significantly reduced the number of relapses, but gave rise to a number of specific problems — seromas and chronic infection of a foreign body, foreign body feeling, stiff-man syndrome, chronic pain syndrome and others - [5]. This is due to the fact that the reparative process proceeds with a pronounced inflammatory component as a reflection of the body's reaction to the endoprosthesis material. Currently, the problem of male infertility after surgical treatment of inguinal hernias is being actively discussed, which, apparently, is associated with the same inflammatory process around the endoprosthesis - [12]. Therefore, the synthetic material used for hernioplasty should be characterized as elastic, resistant to infection, not causing pronounced inflammatory reactions, porous, possessing mechanical and physical strength, not carcinogenic [3]. All these properties can be called the biocompatibility of the implant. Such properties are expressed differently in different materials, but monofilament polypropylene meshes are the most common [12]. The main polymers for the production of surgical meshes are polypropylene, polyester and polytetrafluoroethylene, all of which are non-absorbable -
[1]. Nets made of polypropylene are used more often than others, since polypropylene does not undergo biodegradation, has good biocompatibility, which leads to moderate chronic inflammation, relatively not expensive to manufacture. Polyester demonstrates better biocompatibility with a reduced reaction to a foreign body, but undergoes hydrolytic cleavage. Polytetrafluoroethylene behaves in a similar way in the body. Due to the disadvantages of polyester and polytetrafluo-roethylene, most of the new mesh modifications are made of polypropylene. Special modifications of polypropylene meshes are hybrid meshes with absorbable and non-absorbable elements - [5]. The value of the porosity of the meshes, their mass, method of weaving and compositeness in their structure has been scientifically substantiated. All these characteristics have an ambiguous effect on the process of scar formation, on the inflammatory and possible infectious process in the wound - [3]. The introduction of modern biocompatible prostheses into clinical practice has significantly reduced the frequency of autoplasty of the anterior abdominal wall in patients with postoperative ventral hernia and inguinal hernias. As a proven fact, it is currently known and not discussed that the use of mesh prostheses in hernioplasty significantly reduces the frequency of relapses - [5]. Mesh endoprostheses have an important immunobiological property - they cause nonspecific productive inflammation during implantation with the formation of strong scar tissue, thereby strengthening the abdominal wall in the plastic zone - [4]. The reaction of the tissue to the mesh is considered as a chronic wound lasting for many years on the surface of the mesh material and recipient tissues -
[2]. Histological studies conducted by a number of authors of the sections of the operation zone after implantation of a polypropylene mesh explant showed the presence of the same type of phases of the wound process -[1, 2, 4, 5]. Microscopic examination of tissue sections taken after seven days showed the formation of granulation tissue with an inflammatory
component. After 14 days, the formation of young connective tissue with the growth of fibroblasts and the formation of small capillaries was revealed. After 1 month, inflammatory infiltration is sparse with localization mainly around the prosthesis, where multinucleated cells occur, there is also an overgrowth of denser fibrous fibrous tissue with proliferation of small vessels. It follows from this that in a month we can talk about the completion of reparative processes with the formation of dense connective tissue. Three months later, the presence of formed fibrous tissue with granulomas of foreign bodies was noted. Thus, when prosthetics of the anterior abdominal wall with a polypropylene prosthesis, reparative processes occur naturally, according to the phases of the wound process with the formation of a full-fledged connective tissue. Sufficient porosity of explants largely determines their biocompatibility - [2]. Endoprostheses with a pore size of more than 75-100 microns create conditions for successful germination of the mesh by granulations, penetration of leukocytes and resistance to infection. The "dead space" between the mesh and the tissues disappears, there is no need to remove such a prosthesis when the wound suppurates. However, in his study C.Birolini -[1] in an in vitro experiment, he describes the vegetation of microflora in the form of microcolonies in the area of the intersection of the netting threads, which, in case of infection, will complicate the patient's recovery or lead to chronic infection - [3]. A.V. Zhukovsky, in his monograph "Polymer endoprostheses for hernioplasty", also writes that resistance to infection depends more on the porosity of the explant. The first and relevant to date is the classification proposed by P. Amid in 1997. According to the classification of P. Amid (Amid P., 1997), there are four types of mesh prostheses: type I - prostheses with large (more than 75 microns) pores, which is necessary for the penetration of macrophages, fibroblasts, blood vessels and collagen fibers; type II - prostheses with small (less than 10 microns) pores; type III - prostheses with large pores
хирургия 18
connected from complex filaments having small inter-fiber pores; type IV -biomaterials with very small (submicron) pores that cannot be used as an endoprosthesis for hernioplasty on their own, but can be used in combination with type I prostheses as an anti-adhesive layer. Chronic infection of the material is possible with pore sizes less than 15 microns, since microorganisms easily penetrate into them (size about 1-2 microns), but macrophages (18-35 microns) and leukocytes (15-20 microns) cannot enter, i.e. phagocytosis is difficult - [1]. The presence of a nutrient medium in the wound and a favorable temperature contribute to the colonization of the endoprosthesis by microflora - [2]. Speaking about the biocompatibility of the explant, it must be remembered that the prognosis of surgical treatment depends not only on the prosthesis used, but also on the concomitant pathology. A striking example of this inverse relationship is patients with obesity. The inflammatory process in obesity as a response of the body to injury begins directly in the adipocytes. Adipose tissue has endo-, auto- and paracrine functions, and promotes the development of inflammation - [1, 5]. In experimental studies during implantation of the mesh in obese patients in primary infected tissues, excessive growth of granulation tissue with increased formation of interstitial collagen was recorded against the background of altered immune reactions: violations of the ratio between CD4 and CD8 lymphocytes, a decrease in the number of T-helper cells, activation of Ig G and M synthesis, increased macrophage reaction - [1, 3].
Thus, in the treatment of postoperative ventral hernia and obesity, against the background of the already existing suppression of the body's immune system, mesh implantation leads to further suppression of immunity, which is clinically manifested by the development of purulent-inflammatory complications in the wound. Therefore, in the treatment of patients with ventral hernias and concomitant obesity, it is advisable to choose minimally invasive laparoscopic technologies to reduce surgical
19
хирургия
trauma, as well as to use other methods of preventing wound complications - [5, 9, 12]. The pore size of the mesh prosthesis determines its mass. And the preferred parameters when choosing a mesh explant is a large pore size, since this ensures better biocompatibility. Due to the difficulties in measuring porosity, this feature of mesh weaving has been transformed into the term "light-weight" (light), which reflects the thickness of the threads, the size of the pores and, accordingly, the mass of the mesh. Therefore, an additional classification of mesh prostheses was proposed based on the determination of the mesh mass - [1, 3]: ultralight <35 g/m2, light 35-70 g/m2, standard 70-140 g/m2, heavy >140 g/m2. In combination with the P. Amid classification, this classification allows you to organize a large selection of endoprostheses on the market, choose the right explant, because it is the weaving of the mesh and its porosity that largely determine its biocompatibility - [1, 10, 12]. Somewhat later, a number of researchers U. Klinge in 2012 and Bellon J. M. in 2014, more complete classifications of endoprostheses for hernioplasty were proposed due to the appearance of new types of explants. U. Klinge and co-authors proposed six types of prostheses: macroporous, fine-porous, meshes with special properties, nonporous meshes in the form of films, 3D meshes and biological prostheses - [13]. C.Birolini identified four types of meshes: mesh, laminar, composite, biological prostheses - [1, 2]. Trying to organize ideas about modern endoprostheses, M.V. In 2015, Anurov analyzed their various classifications and formed his classification according to the structural and functional principle, distinguishing membrane, composite, biological and 3D prostheses - [2, 5, 7]. Randomized studies have so far proved that there are no significant differences in the frequency of relapses after the use of "heavy" and "light" non-absorbable mesh prostheses - [1, 3, 4, 6, 9, 12]. When using non-absorbable meshes, the frequency of hernia recurrence is slightly reduced, compared with the use of partially absorbable meshes. However,
the use of "heavy" nets leads to a significantly higher risk of chronic pain after surgery - [12].
Thus, all the variety of prostheses for hernioplasty reflects a deep study of the biomechanical properties of the anterior abdominal wall, the desire of modern surgery to restore not only its integrity, but also functionality and anatomicity. The search is underway for the ideal prosthesis for each type of hernia and the method of operation.
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